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Bladder cancer forms when the lining of the bladder wall
undergoes a mutation,
that helps those cells to grow in an uncontrolled fashion.
There are two different distinct pathways of the bladder cancer.
The higher grade cancers progress by a certain pathways,
and a lower grade cancers progress by a certain mutational
pathways.
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Most well known risk factors for bladder cancer is smoking,
occupational exposure to chemicals, family history of
bladder cancer, certain chemotherapy agents, pelvic
radiation, and certain parasitic infections of the bladder.
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Bladder cancer is a suspected by finding blood in the urine,
sometimes it's visible and
sometimes its a only visible under a microscope.
Also by presence of irritative symptoms of urination,
such urgency, frequency or pain during urination.
When the bladder cancer is suspected, the work up includes
examination of the urine for malignant cells, looking inside
of the bladder with a telescope, which is called a cystoscopy,
to identify and biopsy the cancerous lesions.
And if needed, the radiologic examination is performed to
identify the extent of the bladder cancer.
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So the bladder cancer treatment has two major branch points.
One is influenced by the grade of the cancer, and
the other one is influenced by the penetration of the cancer in
the bladder wall.
The low grade cancers are usually treated by removal of
the cancer's lesion,
which is called the excision of the bladder tumor, and
sometimes then single installation of chemotherapy
is needed, and sometimes there are additional chemotherapy but
they're intravesical, that are needed as well.
If the cancer doesn't return after a single installation,
there's still a periodic surveillance that's needed
to monitor for the recurrence of the cancer.
Higher grade tumors require more aggressive therapy,
the bladder can still be left in place, but they require more
frequent surveillance, and if they progress or
if they become resistant to chemotherapy,
then the extirpative surgery becomes an option.
The bladder has three layers and although all three layers
are equally important in staging the tumor,
the most important distinction comes when the bladder
cancer penetrates into the muscle of the bladder wall.
So the lower stage tumors, which are the non-muscle invasive,
usually are treated by saving the bladder and
resecting the tumor.
When the tumor penetrates into the wall of the bladder,
the muscle of the bladder, then keeping the bladder in place
becomes a less preferred option.
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When the bladder cancer doesn't penetrate the muscle, resection
of the tumors with preservation of the bladder is an option, and
it's not a very complex surgery.
However, it still should be perform by people who
are familiar with the latest evidence based guidelines to
minimize the risk of progression and
the recurrence of the bladder cancer.
When the bladder cancer grows into a muscle wall,
resection is not a very good option at that time.
So the treatment becomes the removal of the bladder, and
the reconstruction of the new bladder, or diversion of
some sort, with some combination of chemotherapy.
When bladder cancer grows into the muscle wall,
then the preferred treatment option becomes surgery
with chemotherapy before, or after surgery.
In general, this is a technically challenging surgery,
and should be performed by specialized urologists who
are familiar with it.
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In general,
there are three different types of urinary diversion.
The simplest one is an incontinent stoma that
drains urine in a bag.
The second type is a neo-bladder which is a continent urinary
diversion that's made out of bowel, and placed in the pelvis
that's most anatomically similar to the pre-existing bladder.
And the third type is a catheterizable continent pouch,
which is also made out of a bowel, and it's attached
to the abdominal wall with catheterizable stoma and
the patients can drain the urine by inserting a catheter into it.
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So the urinary diversion is chosen based on the absence of
counter indications, from the patients perspective and
on the surgeon's preference.
It's shown time and again,
that when patients go to a high volume centers with surgeons
who are used to performing certain types of diversions,
they end up getting more of the continent diversion types.
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Some patients can be candidates for bladder preservation.
It requires a tri-modal therapy, as we call it,
which involves the aggressive resection of the tumor,
leaving the bladder in place, chemotherapy and a radiation.
Some patients are not suited for that, so
it has to be very carefully chosen for certain people.
And the results are not as good as we'd wish,
because some people still progress and
require removal of the bladder after a certain period of time.
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We do have a team comprised of multi-specialty groups,
including specialized urologic surgeons, medical oncologists,
radiation oncologists, pathologists, and radiologists
that are very familiar with the treatment of bladder cancer, and
they can help you pick the best treatment for you.
We're also very fortunate to have a Greenberg Bladder Cancer
Institute, which is a one of a kind institution, dedicated to
the advancement of research and treatment of bladder cancer.
We also have a multitude of trials, clinical trials, for
patients with the non-muscle invasive cancers,
muscle invasive cancers, and metastatic cancers.
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